A community-wide program aimed at improving the rural restaurant food environment may hold promise for increasing the availability, identification and promotion of healthier food and beverage options, according to the study ‘Changing the restaurant food environment to improve cardiovascular health in a rural community: implementation and evaluation of the Heart of New Ulm restaurant programme’ published online in the journal Public Health Nutrition.

The research showed that over an 18-month period, across all restaurants in the rural Minnesota community of New Ulm, the availability of non-fried vegetable offerings increased from 63 percent to 84 percent. The availability of fruit offerings increased from 41 percent to 53 percent, and the offerings of smaller portions and whole grains also increased.

While all restaurants evaluated in the community made improvements in healthy menu practices, restaurants that participated in a community-wide program with a simple-to-implement intervention were more likely to meet or adopt those healthy practices than those that did not participate in the program.

The community-wide restaurant program was conducted in conjunction with Hearts Beat Back: The Heart of New Ulm Project (HONU), which is designed to reduce community members’ risk factors for cardiovascular disease. HONU is a population health demonstration project of the Minneapolis Heart Institute Foundation® (MHIF) in partnership with Allina Health’s New Ulm Medical Center and the community of New Ulm.

“In a community where obesity and low fruit and vegetable consumption have been identified as problems, we were very pleased to see an increase in the number of restaurants that offer fruit and vegetables and smaller portions,” said Rebecca Lindberg, MPH, RD, director of population health from Minneapolis Heart Institute Foundation, and member of the research team. “This represents a significant improvement in the food environment of this rural community.”

Various studies have shown that eating meals away from home may be associated with rising prevalence of overweight and obesity. “People often eat more calories and have poorer diet quality as a result of larger portion sizes, fewer fruits and vegetables, and increased consumption of foods higher in fat and sodium and lower in fiber,” said Lindberg. “We wanted to see if we could facilitate changes in the restaurant food environment in a rural community to mitigate risk factors for cardiovascular disease by making it easier for residents to make healthier choices while eating out,” she said.

The NEMS-R Assessment Process
HONU conducted a baseline nutrition assessment of all 32 restaurants in New Ulm that focused on 16 Healthy Practices derived from the Nutrition Environment Measures Survey for Restaurants (NEMS-R). The survey instrument was specifically created to assess dietary factors in the restaurant food environment related to risk of major chronic diseases such as obesity, diabetes and cardiovascular disease. By focusing on the 16 Healthy Practices, the research team felt the changes would be more feasible for restaurants to implement, as this approach did not necessitate undertaking a large-scale menu revision. For example, the 16 Healthy Practices included offering items with more fruits and vegetables and fewer total calories, using healthier fats when cooking, offering whole grains, and also options for smaller portions. All 32 restaurants were then re-assessed 18 months after the baseline assessment.

Following the baseline assessment, each restaurant received a customized report on how they could increase the availability and promotion of healthful options. Each restaurant was also invited to participate in a HONU-coordinated restaurant program at one of three designated achievement levels — bronze, silver or gold — based on the total number of the 16 Healthy Practices it adopted. Participating restaurants received consulting services from a registered dietitian, training for restaurant staff and local promotion of the restaurant’s participation.

More than one-third (38 percent) of the 32 community restaurants chose to participate in the HONU restaurant program which for most meant actively modifying their offerings. This level of engagement of the community’s restaurant owners and managers as partners in improving the health of the entire community was encouraging. At baseline, 22 percent of all restaurants met the Healthy Practice criteria to attain at least a bronze-level designation. At the follow-up assessment, this increased to 38 percent, with most of the improvement seen among participating restaurants that were independently owned. Because all restaurants were given reports about how they could improve offerings and achieve levels, some implemented changes even though they did not join the restaurant program. Often these changes were ones that would significantly increase the availability of healthful offerings (e.g., half-portions, non-fried vegetables and fruit without sugar).

In addition to showing how a focused food environment program can impact a rural community overall, Lindberg said the research findings also shed light on how population health initiatives can provide assistance to independently owned restaurants in particular.

“While chain restaurants were more likely to have sufficient Healthy Practices in place to meet one of the program levels at baseline, independent restaurants were more likely to both join our program and to make changes,” Lindberg said. “At the end of the follow-up period, there was no change in the proportion of chain restaurants meeting a level, while the proportion of independent restaurants meeting a level had more than doubled.”

More information on the HONU Restaurant Program is available at www.heartsbeatback.org/NewUlmEats

The full article ‘Changing the restaurant food environment to improve cardiovascular health in a rural community: implementation and evaluation of the Heart of New Ulm restaurant programme’ is available to download for free until 29th January 2017.